'Sicko's' Peeno Sees Few Gains in Health InsuranceDr. Linda Peeno has spent two decades fighting a health insurance industry she was once a part of. Giants such as Humana say the industry has greatly improved patient care. But Peeno says after Michael Moore's Sicko opened, she was once again swamped with e-mails of insurance horror stories.

The Humana headquarters sits near the waterfront in downtown Louisville, Ky.

Vikki Valentine, NPR

Director Michael Moore's frontal attack on the U.S. health care system hasn't exactly been among this summer's blockbusters. But a new poll from the Kaiser Family Foundation finds that the movie Sicko has boosted the national conversation about health care.

Nearly half of those surveyed said they had either seen the movie or heard or read something about it. And one in four people said the film prompted a discussion about the U.S. health system.

Those who did see the movie probably remember Linda Peeno. She's the Louisville physician who testified before Congress in 1996, during the height of the national debate over patients' rights versus HMOs. Here's a snippet of Peeno's testimony, as depicted in Sicko:

"I am here today primarily to make a public confession. In the spring of 1987, as a physician, I denied a man a necessary operation that would have saved his life and thus caused his death. No person and no group has held me accountable for this because, in fact, what I did was I saved the company a half a million dollars. "

Reigning in Medical Abuses

Now, 20 years after Peeno denied that heart transplant for a patient while working as a claims reviewer for insurance giant Humana, she's still haunted by the sense that she knew in her heart that what she was doing wasn't right.

"I was actually told at one point — we're using your medical expertise to validate our economic decisions," she says. "So I was already cued in to the fact that I was using my medical knowledge at times illegitimately."

Peeno reached that conclusion with some sadness, after she came to understand her misconceptions about managed care. She had thought it would correct the overuse of medical care she had seen as a resident in internal medicine and infectious disease.

In her physician training, Peeno said, she "saw abuses at the other extreme." She saw surgeons look for potential patients in other departments. They would then perform surgical procedures on the patients, regardless of whether the patients needed them, Peeno said.

Peeno reviewed care at a Louisville hospital before she worked at Humana.

Once there, she soon realized she would have to do a lot more than just rein in unnecessary care. Peeno says at Humana, she was expected to deny at least 10 percent of claims. Approvals were always questioned by superiors, but denials never were, she says. And then came the heart transplant case.

An Approval Reversed

"I actually called and approved it," she says, recounting the story. "And then it was just like all hell breaks loose. 'Oh my gosh, you approved it, you can't. It's a half a million dollars.' "

But within minutes came some surprising news. It turned out that the patient's employer had specifically excluded transplants from its benefits package. That meant it wasn't even Humana's decision to make. Peeno's initial approval was quickly reversed. She said she still had doubts. She wondered how a patient whose insurance didn't cover transplants had gotten on the transplant waiting list in the first place. But no one seemed to care, she said.

"I was told I'd done a good job. Congratulations. That I'd saved the company half a million dollars," she says. "It was just, as I came to understand it, you're sitting on the 23rd floor of a marble building 1,000 miles away, and all you're focused on are the numbers and the dollars. You can see how you get wrapped up and disconnect from the fact that this is a real patient."

An Arresting Work of Art

The pain of what she had done really hit home a few days later. Peeno was walking through the marble lobby of the vast Humana headquarters. She saw workers installing a sculpture.

"What struck me then, because I know so little about modern art and I didn't have a clue as to how much it cost, was how ugly it was," she says with a laugh.

But the very next day, she ran into a nurse who told her something she found not funny at all. The nurse's husband worked in the accounting department, and he had seen an invoice he thought was for that statue.

"That was the jolt," she says. "Here I've just saved the company a half a million dollars, and they've just invested a half a million dollars in this ugly piece of sculpture."

As it turned out, the nurse was wrong. The skinny bronze statue of a woman by the famed artist Alberto Giacometti actually cost more than $3 million. Peeno was told that some years later by the brother of a former Humana chairman.

By then, Peeno had long since left the company, and the statue had long since been sold. Yet Peeno and Humana remain linked. To this day, every time she pops up in public, a Humana spokesman is ready to shoot her down.

"She's represented in the film as having made a decision, to quote her, causing the death of a person. That didn't happen. The person was discharged from the hospital. He lived," Noland said.

Well, says Peeno, with a sigh — yes and no. It's an argument she's had again and again over the years. It's true that the patient was discharged from the hospital, she says.

"So that meant instead of him dying right away, he lived 20 months in cardiac hell before he did die," Peeno says, "so I thought that was a very heartless argument to make."

Not Your Father's HMO

Noland, however, fires back that the story is too old to still be a valid snapshot of the health insurance industry in general and Humana in particular.

"The phrase you hear a lot is, it's not your father's HMO. And that's an actual fact. It's a provable fact," he says. "The system has changed completely in 20 years, and it's changed, frankly, in response to consumer demands and needs. In the '90s, there was a tremendous amount of frustration because health plans were by-and-large in the business of saying no. Now, they're in the business of saying yes."

But Peeno says if that were the case, she wouldn't still see so many people being treated badly by their insurers. In just the first weekend after Sicko opened, Peeno says, she got dozens of e-mails from patients.

She says the e-mails have "the most horrible, complicated, tragic stories. And when I first would start hearing all these things, I would try to do whatever I could. I would help them. I would have them fax me material; I would help them write their appeals."

These days, Peeno works from a tiny office in the small house she shares with three cats and a black hamster named Matryoshka. She makes a living testifying from time to time as an expert witness in cases against insurance companies and lecturing on patient advocacy. For the past year and a half, she's also been studying ethics and theology at a local seminary.

Waiting for a New Approach

It hasn't been easy. Peeno says her emotional low point came last summer, when she was asked to deliver a talk to a religious group. Initially, she says, she was excited.

"I thought I would go in and ... I wouldn't have to argue for things like health care being a right, and our need to take care of one another. And I was really stunned by some of the people's response. Things like, 'Well, I don't want my tax dollars to go to take care of those people.' "

After the talk, Peeno went home, picked up her granddaughter, and went and sat in the park by the river.

"I don't think I ever hit a moment where I was so depressed," she says, "because I thought, if you can't convince people who, out of their religious faith, ought to be thinking differently, God help us."

At the moment, Peeno is one of those 47 million Americans without health insurance. At age 57, she says she can't afford the cheapest policy sold in the state. But Peeno says she's not ready to give up on trying to reform the health system just yet.

"For years, I kept thinking some health plan was going to call and say 'Linda, we really want to do things right, and we know that you have a deep understanding of how these things are, and you care about patients, and we'd love you to help put systems together that are patient-centered.' And then I could just actually do something positive."

Review by Bob Mondello

Moore's tactics are as provocative as always — a trip to Guantanamo, for instance, to demand that three ailing Ground Zero rescue workers get the same free health care the U.S. government affords suspected terrorists. There's plenty of grandstanding, most of it very funny. And in this instance, all that sizzle is selling the steak.

A Snapshot of Health Care in America

Michael Moore's new movie Sicko details problems in the U.S. health care system. At one point, he asks, plaintively, "Who are we?" He's asking how is it that Americans, as a people, are supporting the current system.

NPR Interview with Moore

NPR's Madeleine Brand interviews Michael Moore before a premiere of Sicko on Skid Row in Los Angeles, a notorious location for so-called "patient dumping" by local hospitals. Moore says he believes his movie will motivate Americans to fix the health-care system.

Director Michael Moore has found critical and popular success with documentaries that blend comedy and pathos to attack powerful interest groups. But those films are nearly always challenged as misleading. His latest work, Sicko, is an indictment of the U.S. health care system, highlighting insurance horror stories and profiling countries with universal health care.

Melissa Block sizes up Sicko — as entertainment and expose — with film critic Bob Mondello and science correspondent Joanne Silberner, who covers the health industry for NPR.

Melissa Block: Michael Moore does what he does quite well, which is to mix tragedy and comedy, back to back.

BOB MONDELLO: At the very beginning, he starts out with a whole bunch of horror stories; they're absolutely grim, and you look at people who are deprived of care because they can't afford it. And he does a lot of clever things to make the reasons for this funny. For instance, he uses the Star Wars theme, and he shows all of the various reasons you can be denied coverage by your insurance company, rolling away on the screen — it's thousands of them. Then Moore starts suggesting that there are other places where health care works better, for instance, Canada, Britain and France, and even — this is the shocking one — Cuba. As he shows other systems, I think it is a very persuasively put-together picture of the health care problem, and it's also very, very funny.

I wonder if there is a moment in this movie that you thought worked especially well?

MONDELLO: The sequence when he goes to Britain. He talks to the people at the National Health Service hospital about the cost of the care they're getting. And you can see that as soon as he mentions money, their brows furrow, and they can't get their head around the questions. They have almost literally never thought about money and medicine in the same breath. I think that is so telling, because I know when I go to a doctor or to a hospital, it is almost the first thing I'm thinking of — "Oh my God, how much is this going to cost?"

Let's talk about some of the medical cases Michael Moore describes in this film. At the very beginning, there is one about an American man who loses the ends of two of his fingers in an accident with an electric saw. He did not have insurance. The man must choose between having his middle finger reattached for $60,000, or his ring finger for $12,000. The man chooses his ring finger. How can a man be put into the position of making that choice?

JOANNE SILBERNER: [In the U.S.,] the hospital doesn't have to give him care unless it's lifesaving care, and his life wasn't threatened by the loss of two digits. So the hospital was within its rights to say, "We can reattach your two digits, but it's going to cost you." The irony is that if he had insurance, the insurance company would have paid far less than $12,000 or $60,000. The insurers can negotiate rates with hospitals that individuals can't.

There are also a number of times in the movie where we hear from people who either work or used to work inside the health care system, either turning down applicants for insurance, denying claims...

SILBERNER: He had an insurance company employee who started crying when she described what she had to do in terms of talking with people who called in.

Moore contrasts the U.S. system with the systems in France, Britain and Cuba, where care is free. He claims there's no waiting, and you can choose your own doctor. And in France, he says, there are doctors who make house calls in the middle of the night. How accurate are those claims?

SILBERNER: I think some of the things that those countries are willing to pay for are things that we Americans would not be willing to pay for. There was also the remarkable revelation that in France, when you're a new mother, a government employee will come to your house and maybe even do your laundry and make you soup. That's not going to go over well in this country.

What about the notion that long lines for health care in other countries are a myth?

SILBERNER: Moore didn't really look at the other side of that. What happens in each of these countries is that they get near to crisis situations, where there are lines — this has happened in Canada, too. And then the government, under pressure, puts more money into the system, and the lines go away. But then they come back. It's a cyclical thing; those lines come and go.

One thing did bother me with presenting Cuba as a paragon of health care, while showing the 9/11 workers who couldn't get care in this country: Moore didn't point out that, on that famous chart where the U.S. comes out 37th in health care, Cuba comes out 39th. So I'm not sure that was the best comparison for him to make.

MONDELLO: On the other hand, that is not necessarily something we should be terribly proud of — being 37th in a chart where France is No. 1.

One of the things he does that's very clever is to try to destroy the myth that socialized medicine is so terrifying. When you see what is probably the most impressive hospital I've ever seen, in Cuba, and it looks like a gigantic Hyatt hotel, it's simply not what you were picturing. We were joking when we came out of the film that it was probably the only MRI machine in all of Cuba, and it may very well have been. But the fact of the matter is that it was there and it was able to help a patient. The rooms there did not look decrepit and old, which is kind of what I expected.

SILBERNER: I think there's an issue of expectations. What do the Cubans expect? What do the French expect? What do the British expect? We expect to be able to get drugs like a recently approved drug for cancer that adds 13 days to life at a cost of $4,000 a month. I don't think people would expect that in France or Germany or Cuba. Thirteen days of added life with some side effects for $4,000 a month? We want it, and they don't. When we stop wanting things like that, I think we can move ahead.

In this movie, Moore advocates eliminating insurance companies entirely and going to a single-payer, government-funded system. This is not what any of the mainstream candidates this year are talking about.

SILBERNER: No, they're talking about various packages that would make insurance more affordable, give a little more government assistance, and in some cases, create a bit more regulation. They are talking about incremental changes, and this comes from the experience of '93 and '94, when attempts to change the system got nothing changed.

MONDELLO: We've had a lot of pictures recently about Iraq, and we had An Inconvenient Truth last year about climate change. These movies are not going to change policy. But it certainly does change the debate. If you think about the way the administration talked about climate change prior to An Inconvenient Truth, and the way it's talking about it now, I think it's clear that there was a major shift. I'm not sure if the movie is responsible for that, but certainly it changed the way the media dealt with it. It was a very persuasive case. And I think this will be a very persuasive case for a lot of people, too.

This transcript has been edited for length and clarity and may include portions of the conversation not broadcast on NPR.